Ed
Education Provider Application Form
SECTION A: IDENTIFICATION DATA
Please complete the following before submitting this application:
1.Complete all sections by typing the information in the appropriate places.Handwritten applications will not be reviewed.
2.Identify all attachments with your agency's name.
3.Submit original, including all attachments. KEEP A COPY FOR YOUR RECORDS.
4.This application will not be processed without the Education Provider fee.
Name of Individual Submitting Application:Title/Position:
Name of Organization:
Address:
City: / State: / Zip Code:
Business Phone: / Fax Number:
Email: / Website URL:
Are you FCB Certified? Yes No / Credential(s):
There shall be a designated person assuming responsibility for continuing education offerings. The designated person is responsible for maintaining all standards required of FCB Education Providers.
Is the individual who is submitting the application the designated Contact Person for your organization? Yes No
If No, then please complete Section B: Contact Person on the next page.
Applying for: / Enclosed:Regular (Level-A) - Complete Sections A, B, E, G, & H / $300 Provider Fee (A)
Single Event (SE) - Complete Sections A, B, C, D, & H / $150 Provider Fee (SE)
Check the servicecategory(ies) for which you provide continuing education:
Addiction Mental Health Child Welfare Peer Services Prevention/CHW
Recovery Residence
Check the box to indicate for whom will you be providing educational events:
The Public Employees and the Public Employees only Students (academic setting)
Your organization can best be described as a:
Addiction Service Agency
Child Welfare Agency
Mental Health Agency/Hospital
Other Healthcare Facility
Licensed DUI Program
Private Training /Education Institution
Private Practitioner
University/College/Community College
Government Agency
Please check the type(s) of continuing education programs for which you are applying(check all that apply):
Traditional training/face-to-face events
Online courses:
Instructor-led
Self-paced
Homestudy
Print materials with post-test
Audio or video with post-test
Other, please describe:
SECTION B: CONTACT PERSON
(if different from the individual submitting the application)
Name of Individual Submitting Application:Title/Position:
Name of Agency:
Address:
City: / State: / Zip Code:
Business Phone: / Fax Number:
Email: / Website URL:
Are you FCB Certified? Yes No / Credential(s):
SECTION C: SINGLE EVENT DATA FORM
(for Level SE ONLY)
Type of Educational Offering:
Conference Stand-alone Workshop/Seminar Other:
Has this event been approved previously by the FCB? Yes No
If Yes, when (Month/Year):
Conference or Course Description
Purpose/Target Audience:
Synopsis of educational topics:
Instructional strategies used in this event:
Learner Objectives - Describe the expected learner outcomes:
Qualifications of Instructor(s):
Attach promotional materials (i.e., conference or workshop brochure, participant handouts) or other supporting documents that will facilitate the review of this educational event.
SECTION D: EDUCATIONAL OFFERINGS– For Level A
You must submit instructional materials for three (3) separate educational offerings. Samples must be for courses that are a minimum of one contact hour and must cover the variety of education types offered by your organization (i.e., traditional training, online course, homestudy, etc.). If you offer online courses and/orhomestudy products, at least one sample MUST be the complete online course and/or homestudy product including the post-test.
Please complete all of the data fields by typing directly into the table for each educational offering sample. Indicate the materials that are attached for more in-depth review of these educational offerings. For online courses, you must provide access for review of courses, if requested by FCB education review staff.
Educational Offering 1
Title: / CEUs:Target Audience:
Type of Education:
Brief Description:
Learning Objectives:
Method of Course Evaluation (attach evaluation summary for a past offering of this educational offering):
Materials Submitted for Review (curriculum, course brochure, homestudy products, etc.):
Educational Offering 2
Title: / CEUs:Target Audience:
Type of Education:
Brief Description:
Learning Objectives:
Method of Course Evaluation(attach evaluation summary for a past offering of this educational offering):
Materials Submitted for Review (curriculum, course brochure, homestudy products, etc.):
Educational Offering 3
Title: / CEUs:Target Audience:
Type of Education:
Brief Description:
Learning Objectives:
Method of Course Evaluation(attach evaluation summary for a past offering of this educational offering):
Materials Submitted for Review (curriculum, course brochure, homestudy products, etc.):
2016 FCB Education Provider Application – Page1
SECTION E: PLANNING AND DEVELOPMENT - for Level A ONLY
Please describe the structure, policies and procedures that demonstrate that your organization has the ability to provide effective educational events, professional development, and continuing education opportunities for FCB's certified population. You may provide a narrative, copies of existing policies and procedures, and samples of work products as necessary and appropriate for each category. Please be sure to clearly reference supporting documentation so that the FCB staff can easily locate referenced material.
TYPE YOUR RESPONSE DIRECTLY UNDER EACH QUESTION
Category 1:Organizational Overview
Please describe, in detail, the following:
1.What is the purpose/mission of your organization?
2.How long have you been in business? If your primary mission is not training delivery, please also indicate how many years the agency has been offering training events.
3.How are your training events delivered? Please describe all delivery formats you employ.
Category 2: Curriculum Planning and Development
Please describe, in detail, the following:
1.How do you determine what courses to offer?
2.How frequently do you reassess training needs?
3.How do you determine the program outcomes and learning objectives for each course offered?
4.How do you ensure that course content is relevant, current, and accurate?
5.How do you ensure that the trainer is qualified to deliver the course content?
6.How do you evaluate the effectiveness of delivered courses?
7.What is your process for quality assurance/quality improvement of courses?
Category 3: Administration
Please describe, in detail, the following:
1.How do you announce training events?
2.What records do you maintain regarding course registration, participation, and delivery?
3.How do you respond to complaints or grievances from training participants?
SECTION F: AFFIDAVIT
My signature below certifies that I have read the information on this application and the information supplied is true and correct.I understand misinformation will result in revocation of my provider status.I agree to abide by the requirements set forth by the Florida Certification Board for all continuing education programs offered by my organization.
I further consent to an audit or interview by FCB Board/Staff member if deemed necessary by the FCB.
______
Signature:Date:
Please print, sign, and email or mail this application and supporting documentation to:
The Florida Certification Board
1715 S. Gadsden Street
Tallahassee, FL 32301
Attention: Education Provider Application Specialist
Email to LaTonya Randolph at
2016 FCB Education Provider Application – Page1